At last, here is Part 2 of tornadoes – what they can do to you, and how to maximize your safety. So far, 2013 has been a “good” tornado year, with only 3 fatalities in the United States. But 2/3 of the year remains, so get your plans dusted off and ready to use.

The Risk of Bodily Harm from Tornadoes

Head Injuries

When you get right down to it, most people worry primarily about death or injury. So how dangerous are tornadoes? If you live in Bangladesh, tornadoes are bad news –they have only one tornado every few years, but the combination of high population density, poor socioeconomic conditions, and lack of warning results in hundreds of deaths for a single event. In the United States, if you add fatalities from all tornadoes in a given year, there were only 4 years since 1980 that had over 100 total deaths. Most years have less than 50. 2011 was a big exception – our second worst ever with 553 deaths. Most occurred from the Dixie Alley outbreak of 345 tornadoes between April 25 and 28th (including 36 tornadoes rated F3-F5), and the Joplin, Missouri F5 tornado on May 22. Yet in 2012, the US tornado fatality rate was back down to 68. Obviously, your personal risk of death by tornado is extremely low. In fact, it’s similar to the risk of death by lightning strike – a danger which rarely crosses my mind.

DMAT team helping injury victim. Photo by Jocelyn Augustino.

Morbidity and Mortality – What Happens to Humans?

As a disaster physician, I often wonder about injuries and causes of death. Luckily, morbidity and mortality reports from major disasters occasionally appear in the medical literature. In the April 2011 tornado outbreak, 90% of the injuries occurred indoors, yet they recovered 37.0% of the bodies (ie fatalities) outside – supporting the need for “shelter from the storm”. Being outside in a tornado is bad news. 96% of the April deaths resulted from multiple system trauma, including 22% with head injuries. Data from several large tornadoes suggests that most deaths occur at the scene and result from severe head injury, cervical spine trauma or crush injuries. In the 2011 tornado outbreak, 20 deaths were not directly caused by the tornado, including seven from smoke and carbon monoxide poisoning (fires are a recurring problem after disasters), three from medical equipment failure during power outage (vulnerable populations), and two from falls or injuries during cleanup (responder safety) – 6% of total deaths!

What tornado injuries should healthcare prepare for? Most are standard lacerations, fractures, and blunt trauma. The problem is just the number. After Joplin, each emergency room patient had an average of four injuries. Contamination of wounds by soil and environmental pathogens is a huge problem. Since humans are rarely exposed to these germs,we have little ability to fight them off. In Joplin, 13 patients developed a rare infection called mucormycosis – a fungus normally found only in soil and wood, and a third of them died! Other unusual infections are common – you just can’t treat tornado wounds like routine trauma. In the field, clean wounds thoroughly with soap and water, remove obvious foreign bodies, apply antibiotic ointment and instruct the patient to check the wound regularly for signs of infection ( if not receiving further medical care). Lacerations often need delayed wound closure instead of immediate suturing.

Some other medical tidbits:

Spinal cord injuries involving the thoracic or lumbar spine are common. Use backboards when possible.

Hospitals in tornado country need plans for emergency movement of patients to interior rooms and corridors, carrying equipment with them. Hospitals also need plans for mass evacuation. I doubt any hospital will remain functional if hit head-on by a F4 or F5 tornado.

Staying Safe in Tornado Country – Planning for Shelter

Entrance to a storm shelter. Photo by Peggy Davis.

If you live in tornado country, you should have a shelter plan. Storm shelters are best, followed by basements. (If you are building, consider adding a storm shelter or constructing a safe room). The next best alternative is a first floor interior room without windows, such as a closet, internal bathroom, or under a staircase. Get as many walls between you and the outside as possible. Flying debris causes more serious injuries and death than building collapse, so store covering in your safe spot, such as mattresses, sleeping bags, or blankets – anything to insulate your body from debris. Make sure you have a radio, batteries, flashlights, first aid kit, and other emergency supplies in your safety location. Check out The Safest Place During Tornado video from The Weather Channel – a nice combo of humor and information.

In larger buildings such as apartments or schools, when basements and interior rooms are not available, choose interior hallways or stairways on the lowest floor possible. If you are in tornado country, always know where to take shelter – not just at home, but also in schools, churches, and stores. Long span roofs like grocery stores or gymnasiums are particularly dangerous – look for small internal rooms like bathrooms, employee areas, or storage. Check for signs directing customers to pre-planned safety spots. Even when you’re visiting or driving through tornado country, keep shelter plans in the back of your mind. Even though I live in Oregon, I subconsciously identify shelter and evacuation plans wherever I go – not just for tornadoes, but for many emergencies.

Mobile Home vs tornado – tornado wins. Photo by dannyayers

Most importantly, avoid mobile homes in tornado zones, even if tied to the foundation. The risk of serious injury or death is 12-35 times higher in a mobile home than in a regular house. In fact, the risk is even higher than being outside – talk about crazy. DO NOT STAY IN A MOBILE HOME IF YOU HEAR A TORNADO WARNING (personally I’d be out of there even during a tornado watch). Drive or run to the nearest real building for shelter – if you get stuck, even a car is better than a mobile home.

Tornado Watches and Warnings

The United States tornado warning system is awesome, if you just pay attention to it. Our fatality rate has dropped 96% since the 1920s, primarily because of warnings. In Joplin, 90% of the residents reported receiving at least 5 minutes warning. Unfortunately, 20% of them chose to ignore it, citing reasons such as “hearing warnings too often”, “God will protect me”, not believing a tornado would come their way, and my personal favorite – “seeing is believing”. In a study of 100 survivors, at least three admitted going outside to look for the twister when they heard the warning siren.

A tornado watch means weather is right for tornadoes in your area. Pull out your NOAA radio and listen closely for tornado warnings – don’t count on sirens, which may be difficult to hear indoors, particularly with hail or hard rain. Dust off your emergency plan and check your safety location. Consider putting on sturdy shoes and clothes (stepping on nails is a common recovery injury).

If you hear an actual tornado warning, either on the radio or via siren, go immediately to your safety spot. Don’t go outside! Crouch on the floor with your head as far away from the outside as possible. If possible, crouch under a sturdy piece of furniture (but avoid being directly below a refrigerator, piano, or other heavy object on an upstairs floor). Cover yourself (some people even suggest putting on a bike helmet). Listen to the weather radio (which you of course brought with you) for instructions on when it is safe to come out. Tornado myth – opening your windows will keep your house from exploding. FALSE! (I used to run around opening all the windows when I was child visiting Illinois and there was a tornado watch). There is no evidence that the pressure drop makes houses explode. In fact, opening windows may actually increase damage severity. A violent tornado can destroy a house whether its windows are open or closed – in fact, it will blast them open for you!

Tornadoes in the Great Outdoors

Car after Joplin Tornado – hard to imagine airbags would protect you from this! Photo by Elissa Jun/FEMA.

What if you are out and about when a tornado warning comes? Should you try to outrun the tornado? In general, just get to the nearest sturdy building ASAP. However, if you are driving in an open non-congested area, and if you can see both the tornado and the direction it is traveling (pretty big ifs), you can try escape. Face the direction the tornado is travelling toward (ie. away from the tornado), then drive 90 degrees to your right (usually south to southeast). If traffic, congestion, or lack of roads are a problem, you are better off abandoning your car and seeking shelter. Tornado myth – highway overpasses are a good shelter. FALSE! Overpasses have clearly been shown to funnel wind and debris, increasing risk. Get as far away from trees and cars as possible – they might be blown into you.

If you’re stuck in your car as a tornado approaches, controversy abounds on your best approach. Some experts say put the car in park, and hang tight with your seat belt on, windows up, and doors locked. Put your head below window level and cover your head with hands and a blanket or coat. Although your car may be tossed and turned, you might still come out alive, particularly if air bags deploy. On the other hand, if you see a near-by spot where you can get noticeably lower than the roadway, leave your car and lie flat in the ditch or culvert, covering your head with your hands. A few people recommend driving your car into the ditch, so it is less likely to roll in the wind.

For additional information on preparedness and response to tornadoes and other storms, download the free Thunderstorm, Tornado and Lightning Preparedness Guide from the NOAA (National Oceanic and Atmospheric Administration). While you’re at it, get the Red Cross Tornado app for your smart phone – not only does it tell you what to do before, during, and after a tornado, but it also sounds a warning if a tornado warning is issued, and it has a special “I’m Safe” feature for notifying family.

Tornado Recovery

The tornado is over, and although there is a lot of damage, at least you are safe. WRONG. As many as 50% of tornado related injuries actually occur after the fact. You can get tetanus from a nail, set your house on fire with a candle, or have a heart attack from stress and strenuous activity. Don’t wander around without wearing sturdy shoes, clothes, and gloves, and make sure your children do the same. Electrical sparks, gas leaks, and unsafe use of candles or flames cause many post-disaster fires – check around right away after you emerge from shelter. Take your time and take care of yourself during your recovery efforts. The damage will still be there to work on tomorrow – make sure you are as well.

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Sheila Sund, M.D.

I am a physician from Salem, Oregon with a disaster fixation. Having left my previous specialties of neurology and hospice behind for now, I am instead focused on emergency preparedness, particularly healthcare response. Somehow the powers that be frequently forget that physicians will be an essential part of any response and recovery. I stick my head in everywhere to make sure we are included, and in the meantime, learn a lot about emergency response in general.
By Sheila Sund
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